Tuberculosis (TB) is an infectious disease caused by the tubercle bacillus. In India most people are exposed to tubercle bacillus due to BCG vaccination. This vaccination allows the body to make antibodies against the bacillus to make the person immune to TB. Even after this, some people get infected with TB.
Pulmonary TB or TB of lungs is the most common form of TB but other extra-pulmonary forms may also occur. Extra-pulmonary forms of TB generally follow pulmonary TB and occur due to spread of bacillus from lungs to other body parts through blood. When the bacillus gets accumulated into the genital tract, it causes TB of the genital organs. Genital TB is one of the most common causes of infertility in both males and females. It is found in about 1 to 2% of female gynaecological cases in India.
How does TB cause infertility?
Infection of genital tract by tubercle bacillus causes genital TB. Bacillus may travel from primary site to the genital organs through blood and cause genital TB. The infection first affects fallopian tubes followed by the other reproductive organs like uterus, ovaries, cervix, and vagina. In cases of TB infection of fallopian tubes, the infection prevents the entry of fertilised egg to the tube and reaches the uterus. This diminishes the chances of pregnancy. If the bacteria erode the lining of the endometrium, the fertilised egg could not implant itself on the wall of uterus, thereby reducing chances of pregnancy. If the ovaries are infected by bacteria, it would affect the quality of the ovum and its fertilisation may not occur. Similarly, TB infection in the cervix, vagina or the vulva could make chances of pregnancy bleak.
It has been found that fallopian tubes are affected in almost all the cases followed by endometrium (uterine lining) in 50%, 20% ovaries, 5% cervix and vagina and vulva in less than 1% of infected women with pulmonary TB.
In men too, the bacteria may reach the testicular area and cause of epididymo-orchitis. If this is left untreated, it may stop the addition of sperm in semen, thereby causing infertility.
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Symptoms of Genital TB
Genital TB is mostly found in woman of reproductive age when she starts to look for treatment of infertility after trying to conceive. Although in most of the cases the infection can be silent, and may not cause any symptoms or signs at all but some of the following symptoms may be found:
- Weight loss
- Low-grade fever
- Amenorrhea (no menstrual bleeding)
- Menorrhagia (abnormally heavy bleeding)
- Metrorrhagia (abnormal bleeding)
- Oligomenorrhea (infrequent menstrual periods)
- Abdominal swelling
- Bleeding after sexual intercourse
- Difficult or painful sexual intercourse
- Vaginal discharge
Symptoms in males
- Swelling, irritation and pain in the testicles
Diagnosis of Genital TB
Genital TB is always hard to diagnose, because it is a silent invader of the genital tract. The suspicion for TB arises when an infertile woman gives a family or personal history of TB. The doctor may then prescribe the following tests to diagnose genital TB:
Investigations to confirm genital tuberculosis
- Complete blood count
- Chest radiographs
- Tuberculin test
- Menstrual blood for culture
- Endometrial curettage for biopsy
- Histologic examination
- Culture for Mycobacterium tuberculosis
- Peritoneal fluid for culture
- Cervical cytology
- Other serologic tests
Tests for diagnosis of TB infertility:
Performed with a site-specific sample:
- Histopath examination
- Gene Xpert
- Polymerase chain reaction (PCR) Mycosure TB PCR test
- TB culture
- Complete blood count (CBC) and Erythrocyte Sedimentation Rate (ESR)
- Interferon-g release assay (IGRA)
- Chest X-ray
Treatment of genital TB to tackle infertility
After a confirmed diagnosis, prompt treatment is required to kill the bacteria and restore the functionality of damaged reproductive organs to tackle infertility.
Treatment for genital TB: Genital TB can be managed by full course anti-tuberculosis treatment just like treatment of pulmonary TB. The current standards in the treatment of tuberculosis are:
- A 6-month regimen consisting of isoniazid (INH), rifampin (RIF) and pyrazinamide (PZA) for 2 months, followed by INH and RIF for 4 months, in patients with a fully susceptible organism who adhere to treatment.
- A 9-month regimen of INH and RIF is acceptable in patients who cannot tolerate PZA.
- Religious patient adherence to the drug regimen.
Lymphocyte Immune therapy (LIT): It is a kind of antibacterial treatment that is administered for 6–8 months.
Restorative surgery: In some cases bacteria might have damaged the reproductive organs. This damage needs restorative surgery so that the woman’s reproductive organs are restored and reconstructed to make conception possible.
Unfortunately, the chances of pregnancy in women suffering from genital tuberculosis are very poor even after completing the full treatment. But, there is hope for these patients as artificial reproductive technology, mainly IVF treatment, can help in conception.